Associations of American Indian Children’s Screen-Time Behavior With Parental Television Behavior, Parental Perceptions of Children’s Screen Time, and Media-Related Resources in the Home

Introduction American Indian children have high rates of overweight and obesity, which may be partially attributable to screen-time behavior. Young children's screen-time behavior is strongly influenced by their environment and their parents' behavior. We explored whether parental television watching time, parental perceptions of children's screen time, and media-related resources in the home are related to screen time (ie, television, DVD/video, video game, and computer use) among Oglala Lakota youth residing on or near the Pine Ridge Reservation in South Dakota. Methods We collected baseline data from 431 child and parent/caregiver pairs who participated in Bright Start, a group-randomized, controlled, school-based obesity prevention trial to reduce excess weight gain. Controlling for demographic characteristics, we used linear regression analysis to assess associations between children's screen time and parental television watching time, parental perceptions of children's screen time, and availability of media-related household resources. Results The most parsimonious model for explaining child screen time included the children's sex, parental body mass index, parental television watching time, how often the child watched television after school or in the evening, parental perception that the child spent too much time playing video games, how often the parent limited the child's television time, and the presence of a VCR/DVD player or video game player in the home (F7,367 = 14.67; P < .001; adjusted R 2 = .37). The presence of a television in the bedroom did not contribute significantly to the model. Conclusion Changes in parental television watching time, parental influence over children's screen-time behavior, and availability of media-related resources in the home could decrease screen time and may be used as a strategy for reducing overweight and obesity in American Indian children.


Introduction
American Indian children have high rates of overweight and obesity, which may be partially attributable to screentime behavior. Young children's screen-time behavior is strongly influenced by their environment and their parents' behavior. We explored whether parental television watching time, parental perceptions of children's screen time, and media-related resources in the home are related to screen time (ie, television, DVD/video, video game, and computer use) among Oglala Lakota youth residing on or near the Pine Ridge Reservation in South Dakota.

Methods
We collected baseline data from 431 child and parent/caregiver pairs who participated in Bright Start, a group-randomized, controlled, school-based obesity prevention trial to reduce excess weight gain. Controlling for demographic characteristics, we used linear regression analysis to assess associations between children's screen time and parental television watching time, parental perceptions of children's screen time, and availability of media-related household resources.

Results
The most parsimonious model for explaining child screen time included the children's sex, parental body mass index, parental television watching time, how often the child watched television after school or in the evening, parental perception that the child spent too much time playing video games, how often the parent limited the child's television time, and the presence of a VCR/DVD player or video game player in the home (F 7,367 = 14.67; P < .001; adjusted R 2 = .37). The presence of a television in the bedroom did not contribute significantly to the model.

Data collection
Parents completed a 2-part written survey; the first part asked about their child's behavior and the second part asked about their own behavior. Only baseline data from this survey were used in the current study.
Parents reported their child's and their own date of birth and sex. We calculated age at time of survey from the date of birth. Using standard protocols (10), we collected height in meters and weight in kilograms for both children and parents. BMI was calculated as kilograms divided by height in meters squared, and weight status categories were created for both children and parents. For children, Centers for Disease Control and Prevention BMI percentiles for age and sex were used to define underweight as BMI less than 5th percentile, normal weight as 5th to 85th percentile, overweight as 85th to less than 95th percentile, and obese as 95th percentile or higher. For adults, normal weight was defined as BMI less than 25.0 kg/m 2 , overweight as 25.0 to 29.9 kg/m 2 , and obese as 30.0 kg/m 2 or higher. Because poverty is widespread on the reservation The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
(11), a relative socioeconomic status variable was created by using factor analysis. This variable is a composite of 5 areas relevant to socioeconomic status (educational levels of parents, household income, unemployment status, public assistance benefits, resources in the home) and is applicable to this American Indian population only.
The questions used to assess children's screen time, parental television watching time, and parental perceptions of children's screen-time behavior were based on previous research (12). The variables examined in the current study were the child's daily screen time, parental daily television behavior, parental perception of the child's screen time, parental perception of the child's television behavior, inventory of media-related household resources (television, computer, Internet access, VCR/DVD player, video game player, and cable or satellite), and presence of a television in the child's bedroom (Appendix).

Data analysis
We calculated frequencies, means, and standard deviations (SDs) to describe child and parental demographic characteristics, including age, sex, BMI, and BMI z score (children only). We conducted a series of stepwise linear regression analyses to assess the associations between 5 blocks of variables (parental television watching time, parental perceptions of the child's screen time, parental perceptions of the child's television behavior, mediarelated household resources, and presence of television in the child's bedroom) with the main outcome of children's screen time. Seven models were tested to derive the most parsimonious model that explained the most variance of children's screen time. The full model included all variables; subsequent submodels eliminated blocks of psychosocial and resource variables that were theoretically associated with the outcome; and the final model included only variables that were consistently significant throughout the submodels. Intervention condition, child's sex, and parental BMI were retained in each model as covariates because they each differed by child's screen time in preliminary analyses. Child's BMI was not included in the regression model because it was not associated with the outcome variable. All models were adjusted for relative socioeconomic status. Adjusted R 2 values were assessed for each model to determine parsimony. The dependent variable, children's screen time, was skewed and was logtransformed for analysis. For ease of interpretation, we present regression coefficients from the untransformed analysis and the P values from the transformed analysis.
We completed all analyses using SAS version 9.2 (SAS Institute, Inc, Cary, North Carolina).

Descriptive characteristics
The mean age of children in this sample was 5.8 years (SD, 0.51 y), and 30% of them were overweight or obese. Approximately 90% of the parents who completed the survey were female, and their mean BMI was 32.5 (SD, 7.34) kg/m 2 ( Table 1). Parents reported that their child engaged in 3.0 hours of screen time per day, while they themselves engaged in slightly less (2.4 h/d) ( Table 2). Approximately 23% of parents strongly agreed or agreed that their child spent too much time watching television, and approximately 81% felt that it would be easy for them to limit their child's television time. Watching television after school (12.9%) was more than twice as common as watching television before school (4.5%). Presence of media-related items ranged from 31% who had Internet access to 93% who had a VCR/DVD player. Only 5 households did not own a television; more than two-fifths owned 3 or more televisions. More than half of the children had a television in their bedroom (Table 2).

Regression analyses for child's screen time
The regression full model and submodel 5 explained the most variance of children's screen time; however, the final model was the most parsimonious (F 7,367 = 14.67; P < .001), accounting for 37% of the variance with only 8 independent variables ( Table 3). Variables that were significantly and positively associated with children's screen time were the child's sex (male), parental television watching time, parental perception that the child spent too much time playing video games, how often the child watched television after school or in the evening, and presence of a VCR/ DVD player or a video game player in the home. Parental BMI and parental perception of how often they limit their child's television time were significantly and inversely associated with children's screen time. Children whose parents agreed with the statement that they spent too much time playing video games engaged in 1.06 more hours of screen time per day than children whose parents disagreed with this statement. Children whose parents responded that they often or always watched television after school or in the evening engaged in 1.0 more hours of screen time per day than children whose parents responded never, rarely, or sometimes to this statement. Children whose parents often or always limited child television time engaged in .38 fewer hours of screen time per day than children whose parents did not limit television time. Parents of children who had a working VCR/DVD player or video game player reported that their child engaged in 0.70 and 0.33 more hours of screen time, respectively, than parents of children who did not have those resources in the home.

Discussion
Children's screen-time was associated with child's sex, parental BMI and television watching time, parental perceptions that the child spent too much time playing video games, how often the child watched television after school or in the evening, how often parents limited their child's television time, and presence of a VCR/DVD player or a video game player in the home. Television and media have a consistent presence in children's lives (13), and this may not change in the near future. Especially at this young age, parental influence (ie, behavior, perceptions, and availability of household resources) is pivotal in determining children's behavior, as our study demonstrates. The amount of time parents reported that their children engaged in screen time (3.0 h/d) is slightly lower than what has been reported in other studies for similar age groups. For example, parents of 5-to 6-year-olds reported almost 4 hours of screen time (watching television or DVDs, playing video games, or using the computer) on the previous day (13). Less screen time was reported among girls and children whose parents limited their child's television watching. Similar findings related to sex were reported in a sample of non-American Indian 5th-and 6th-graders (14) and similar findings of parental rules related to television use were reported in a sample of non-American Indian 11-to 15-year-olds (15).
The unexpected negatively associated factor in the current study was parental BMI; child's screen time was lower by 0.02 hours per day for every 1-unit increase in parental BMI. The relationship between television behavior and weight status was moderated by parental weight in samples of older children and adolescents (ie, 10-to 13-year-old girls and 14-to 19-year-old boys) but not for children aged 6 to 9 years (16). A cross-sectional study of 8-, 11-, and 14year-olds found that children and adolescents who have at least 1 overweight parent watched more hours of television than those with 2 normal-weight parents (17). It is not clear why the relationship between parental BMI and child screen time is more apparent in older children and adolescents, but it could be because data about younger children's behavior (<9 y) are reported by the parent rather than self-reported, which is the usual method for older children and adolescents. Because of social desirability, parents of younger children may be underestimating their child's screen time behavior, which could bias results.
As expected, parental television watching time and parental perception that the child spent too much time playing video games were associated with increased children's screen time. Parental role modeling of sedentary behavior has consistently been associated with increased sedentary behavior in their children (18,19).
It may be assumed that the availability of media-related resources in the home would increase the time spent engaged in screen time. However, of the 7 resources that were examined in the current study (household television, computer, Internet access, DVD/VCR player, video game player, cable or satellite, and bedroom television) only the availability of a VCR/DVD player or a video game player was associated with increased screen time in young American Indian children. On a national level, which is also reflected in the current study, more than 90% of parents of children aged 5 to 6 years report having a VCR/DVD player in the home (13). It is plausible that the relationship seen between the availability of a VCR/DVD player and children's screen time may be exacerbated because of the oversaturation of this piece of media-related equipment in households.
The increased use of sedentary video games has been cited as a possible contributing factor to obesity in children.
About two-thirds of the current sample reported owning a video game player; the national average for 5-to 6-yearolds is 52% (13). Younger children who played a video game during the previous day tended to spend more than 50 minutes playing electronic games (13), which parallels the findings from this study.

The presence of a bedroom television is associated with
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
increased screen time in older adolescents aged 15 to 18 years (20). However, this relationship is not evident in young children in a nationally representative sample of 8-to 18-year-olds (21) or consistently present in our study. The American Academy of Pediatrics recommends that parents restrict their children from having a television in their bedrooms (22), but 51% of the current study's sample and 37% of 5-to 6-year-olds nationally have a bedroom television (13). However, neither the current study nor a study based on a representative sample (13) supported the hypothesis that the presence of a television in the child's bedroom was associated with children's screen time.
Although young children may have access to a television, the television may not have as much of an influence on their viewing because younger children may not have the same level of autonomy as older children and adolescents to choose when and what they watch on television. Data are unavailable for preschool-aged children, but nationally representative data support that 66% of 8-to 10-year-olds compared with 51% of 11-to 14-year-olds and 26% of 15-to 18-year-olds reported their parents have rules about which shows they can watch on television (21). It is reasonable to conclude that even more than 66% of 5-to 6-year-olds would have such restrictions.
Major strengths of this study are that findings add to the sparse literature on American Indian children and obesity, the population of focus was younger children rather than adolescents, and both physical (ie, media-related resources) and social (ie, parental perceptions) factors were examined. One study limitation is the potential bias for social desirability since data were collected only via parent report. The cross-sectional design of the study prohibits cause-effect inferences; however, our study is a necessary, initial step when exploring mechanisms that may lead to changes in behavior (23). Although our findings may contribute to the prevention of overweight and obesity by limiting sedentary behavior, they are limited to preschool-aged American Indian children. Given that this population is at considerable risk for obesity, these findings may inform the types of attitudes and behaviors that can be targeted for obesity prevention and intervention.
Positive parental involvement and role modeling are necessary for reducing and preventing overweight and obesity at a young age. Parents need to lead by example and teach their children healthy lifestyle behaviors. Results from the current study suggest that changes in modifiable factors such as parental television watching time, parental perceptions of child screen time, and the availability of media-related resources merit further investigation as a means to decrease screen time and consequent overweight and obesity in American Indian children.
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.   The full model included all variables; 5 subsequent submodels eliminated blocks of psychosocial and resource variables that were theoretically associated with the outcome, and the final model included only variables that were consistently significant throughout the submodels. All models retained intervention condition, child's sex, and parental BMI and were adjusted for relative socioeconomic status, a variable that is a composite of 5 areas relevant to socioeconomic status. Abbreviations: BMI, body mass index; NI, variable not included in model; NA, not applicable. a The full model included all variables; 5 subsequent submodels eliminated blocks of psychosocial and resource variables that were theoretically associated with the outcome, and the final model included only variables that were consistently significant throughout the submodels. All models retained intervention condition, child's sex, and parental BMI and were adjusted for relative socioeconomic status, a variable that is a composite of 5 areas relevant to socioeconomic status.